Older People Who Are Frequent Users of Acute Care: A Symptom of Fragmented Care? A Case Series Report on Patients' Pathways of Care

J. Dollard, G. Harvey, E. Dent, L. Trotta, N. Williams, J. Beilby, E. Hoon, A. Kitson, C. Seiboth, J. Karnon

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3 Citations (Scopus)


Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having ≥4 unplanned emergency department (ED) presentations/ admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.

Original languageEnglish
Pages (from-to)193-195
Number of pages3
JournalThe Journal of frailty & aging
Issue number3
Publication statusPublished - 1 Jan 2018



  • aged
  • ambulatory care
  • delivery of health care
  • disease management
  • Frail elderly
  • hospital/*utilization
  • integrated

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